Seeking ways to address chronic pain without narcotics, Medicare is exploring whether to pay for acupuncture, a move that would thrust the government health insurance program into the long-standing controversy over whether the therapy is any better than placebo.
Coverage would be for chronic low-back pain only, a malady that afflicts millions of people. Low-back pain, acute and chronic, ranks as the third-greatest cause of poor health or mortality in the United States, behind only heart disease and chronic obstructive pulmonary disease, according to the National Institutes of Health.
In its request for comments on acupuncture, the Department of Health and Human Services said that “in response to the U.S. opioid crisis, HHS is focused on preventing opioid use disorder and providing more evidence-based non-pharmacologic treatment options for chronic pain.”
The agency said it hopes “to determine if acupuncture for [chronic low-back pain] is reasonable and necessary under the Medicare program.” A proposal is due by July 15, with a final decision by Oct. 13.
Chronic pain — generally defined as pain that lasts 12 weeks or more — is a complex disorder with numerous causes and many possible treatments. But there is widespread agreement that health-care providers have overused powerful opioid painkillers to address it, with little research to support that approach.
Currently, Medicare covers injections, braces, implanted neurostimulators and chiropractic care as well as drugs for chronic low-back pain, under certain conditions set by the program.
Acupuncture continues to gain legitimacy for pain relief in the United States. A 2014 review reported that more than 10 million acupuncture treatments are administered each year. Some insurance companies cover the practice, respected medical institutions offer it, and schools of acupuncture produce new practitioners. The Department of Veterans Affairs has trained 2,400 providers to offer “battlefield acupuncture,” five tiny needles inserted at points in each ear, for pain relief.
Medicare coverage “is long overdue,” said Tony Y. Chon, director of integrative medicine and health at the Mayo Clinic in Minnesota. “The opioid epidemic is going to be the momentum that’s really needed to push not just acupuncture but other kinds of non-pharmacological interventions to the forefront.”
Some proponents also note that acupuncture is one of the safest interventions available for pain — though some accidents have been reported. Even if it works only for some people, they argue, there is little harm in trying it when other options are not effective.
Taken overall, however, research shows that acupuncture is little more effective than placebo in many cases. When the government’s Agency for Healthcare Research and Quality reviewed research on a wide range of therapies for chronic pain in 2018, it found the “strength of evidence” that acupuncture works for chronic low-back pain is “low.”
The National Center for Complementary and Integrative Health, part of NIH, says “research suggests that acupuncture can help manage certain pain conditions, but evidence about its value for other health issues is uncertain.”
For low-back pain, the institute cites a study that found it “more helpful than either no acupuncture or simulated acupuncture.” But another found “strong evidence that there is no difference between the effects of actual and simulated acupuncture,” according to its website.
Critics go further, noting that hundreds of years of anatomical studies have not found evidence of the points in the body linked to the “energy channels” that acupuncture claims to be stimulating to provide pain relief. They contend that acupuncture shows all the signs of the placebo effect, with providers and recipients who believe it works and the elaborate ritual of placing the needles in specially selected spots.
“The whole thing is a big scam,” said Steven Novella, an assistant professor of neurology at the Yale School of Medicine and editor of the “Science-Based Medicine” website. “The only honest interpretation of the data is that acupuncture is a theatrical placebo.”
In part, the controversy has lingered because acupuncture is difficult to study. The practice involves inserting tiny needles into the skin, so patients who do not receive that treatment provide a poor comparison, or “control” group. Researchers have turned to “sham acupuncture,” using needles that appear to pierce the skin but retract like stage daggers. In that way, neither the practitioner nor the patient knows whether acupuncture is being administered, eliminating some of the bias that confounds studies.
A 2018 review of 39 studies involving nearly 21,000 patients has buoyed acupuncture proponents. It concluded that “acupuncture was superior to sham as well as no acupuncture control for each pain condition.”
“With this kind of research evidence behind it, why hasn’t acupuncture been accepted?” asked Vitaly Napadow, a neuroscientist and practicing acupuncturist at the Martinos Center for Biomedical Imaging at Massachusetts General Hospital. “And the reason, in my opinion, is that acupuncture is being held back by philosophy.” Specifically, he said, Western medicine is slow to change despite acceptance of acupuncture by patients because the concepts come from Eastern medicine.
“Not everybody is going to want to try it,” said Lisa Conboy, director of research at the New England School of Acupuncture, part of the Massachusetts College of Pharmacy and Health Sciences. “It’s a different way of looking at the world. I think it makes some people nervous to have a whole other set of medical professionals.”
But Alan Levinovitz, an associate professor of religion at James Madison University, who has studied Chinese thought and medicine, said acupuncture represents the blurring of the lines between ritual and medicine. To the extent that rituals alleviate pain, that is a good thing — but not a reason to cover them with taxpayer-funded insurance, he said.
“One concern would be that we would cover acupuncture as if it were a physiological treatment, when in fact it is a psychological treatment,” he said.
Novella said that the efficacy attributed to acupuncture in the 2018 review could easily be explained by various research biases and that no drug would be allowed on the market based on that level of proof.
“We never get that threshold of evidence that you need in medicine, where you get that persistent effect, and it’s replicable” across numerous studies, he said.